The Psychiatry Blog by John Deri, M.D.

Psychotherapy and Dependent Origination

The Buddhist theory of dependent origination states that all phenomena are contingent on antecedent conditions.  The tree is contingent on the seed, the valley on the glacier and so forth.

This perspective is an extremely valuable lens through which to view the emotions experienced in psychotherapy.  A patient responds to a remark of mine with a mixture of pain and anger.  She has interpreted her therapist’s comment as a callous attempt to exclude her from his inner world.

The therapist knows from previous work with this patient that she had been severely abused by her father throughout her childhood.  Her mother had been completely ineffectual at protecting her daughter from her husband’s rage.  Neither parent had the slightest capacity or inclination to allow their daughter into their minds.  Children will always try to see the parent as “good,” even at the cost of believing themselves to be “bad”.  So, this little girl gradually developed a view of herself as deficient and unworthy.

In her psychotherapy, much work has been devoted to a reconstruction of her memories of this early life trauma.  The terrifying effects of the physical abuse had been greatly compounded by her rage and panic due to her “solitary confinement”.    She had lived her entire childhood utterly alone, despite the physical proximity of her parents.

Freud’s conception of therapeutics had a somewhat cognitive bent.  Remembering the original trauma would afford the patient insight into his own woundedness.  This insight would constitute the vital element that would enable the patient to heal.

Freud’s younger contemporaries, Sandor Ferenczi and Otto Rank, held a very different viewpoint. They believed that only a repetition of the original trauma within the psychotherapy relationship would have the power to heal the patient.  They felt that only through repetition would the patient’s original memories be reactivated with sufficient force and feeling to break through the barrier of dissociation.

The aliveness of the feelings associated with early life trauma, reexperienced within the transference, allows these feelings to be revised and reworked within the context of a caring therapy relationship.

This healing is never a one time process.  In the case of my patient, we repeatedly respond to each other in ways that leave her feeling hurt and excluded.  Each time this occurs, we struggle together to delineate her process from my process.  Each time, we view and review the relationship between the present and the past.  As we do so, she has come to recognize that she does have access to my mind, and to my feelings.  My positive regard for her is genuine and deep.

With each repetition, she emerges stronger and healthier.  The perseverative reenactment of her original wounding, through the shadow play of the transference and the countertransference, engages a gradual but inexorable healing process.  The critical difference between the past and the present is the outcome of the traumatic clash.  In the here and now of the psychotherapy relationship, each repetition of the crisis resolves with enhanced mutual trust and deeper closeness between us.

In her parenting and in her work, this lady has become a beacon of hope and an agent of healing for others.  Within her psychotherapy relationship, two wounded healers have been brought together for the purpose of mutual healing.

I would like to express my deep gratitude to my patient for graciously permitting me to make use of our work in the context of this essay. It is her intention to help to relieve the suffering of others through the sharing of her story.